The Center for Disease Control (CDC) defines Public Health as follows:
“… the science of protecting and improving the health of people and their communities. This work is achieved by promoting healthy lifestyles, researching disease and injury prevention, and detecting, preventing and responding to infectious diseases.”
With the exception of infectious disease management, this entire field of practice could apply to the modern role of the anesthesiologist, and more specifically, the perioperative physician. The role of the anesthesiologist has changed profoundly since the first ether was passed over a patient in 1846. At the beginning, our role was to keep the patient still, and if possible alive, and if he or she were lucky, free of pain. Today, these objectives are largely taken for granted (if not always achieved); our role has, therefore, expanded to include measures aimed at reducing both the short- and long-term harm associated with surgery and anesthesia.
Technological advancements have led to generally improved perioperative patient safety, resulting in further evolution of our pivotal role in the operating room. When serious adverse events occur in association with the delivery of anesthesia, they are potentially devastating; however, they are also thankfully relatively rare. Accidental awareness during general anesthesia (AAGA) occurs in between 1 in 250 and 1 in 19,000 cases depending on the clinical setting, how AAGA is defined, and the method of enquiry. Death or serious injury arising from airway management is similarly unusual and often associated with human factors. Some more prevalent problems do persist, such as intraoperative hypotension, and may be associated with harm however, with the advent of artificial intelligence-delivered algorithms, it is likely that these challenges will also soon be largely resolved.
So, in clinical practice, and in research, where do we look for opportunities to improve? Donabedian’s Structure, Process, and Outcome model provides a useful framework for conceptualizing quality in health care. Essentially, it characterizes the influence of the context in which we work (structure—such as place, people, and culture), and the things that we do (processes—such as investigations and treatments, and their timeliness), on patient outcomes (experience, complications, mortality, and quality of life). In both research and quality improvement endeavors, we put a lot of effort, time, and money into the investigation of intraoperative and postoperative interventions, which might improve patient outcomes: hemodynamic therapy, anesthetic techniques, and analgesic regimens to name 3 common areas of interest. Beyond discovery science, we also recognize the need to study and improve the reliability of how we deliver care using quality improvement and implementation science approaches. A good example of where this is necessary is enhanced recovery pathways: simply writing the protocol is not enough to ensure compliance and, therefore, better results.
All these efforts are worthy and should continue; however, perhaps the biggest overall influence on a patient’s outcome remains his or her general health and fitness, and his or her acute condition at the time of surgery and anesthesia. It, therefore, stands to reason that we should place as much effort into improving a patient’s general condition throughout the perioperative period (starting before surgery) as we do into developing and evaluating interventions, which are primarily focused on the OR. In this respect, might we, the humble anesthesiologists, be considered as public health physicians?
Surgery is a rapidly expanding business, and our customer characteristics are changing. Five years ago, it was estimated that Americans undergo an average of 9.2 procedures in their lifetime. Data from the UK suggest that if current trends persist, 1 in 5 adults over the age of 75 will have surgery each year and data from the United States suggest that 7.4% of elective and 22.3% of emergency surgical patients over the age of 65 die within a year of their operation. Humans do not generally age in good health, and this all adds to the risk of poor outcomes from surgery. The macabre joke of “the surgery was a success, but the patient died” has been discussed in the medical literature for decades. Anesthesiologists have a vital role to play as gatekeepers in the prevention of poor decision-making. Thus, “injury prevention” in the perioperative context could be considered as the avoidance of “wrong patient surgery,” in which the anesthesiologist plays a critical role. Every day, in every nation, people undergo procedures aimed at improving quality and/or duration of life, but instead lead to complications that leave the patient in worse condition than before surgery. In many of these cases, the harm arises from predictable risk factors, such as low functional capacity or poorly controlled long-term conditions. Either opportunities to optimize health preoperatively are not taken and/or patients may be unaware of their individualized risk of poor outcomes when they consent to surgery.
So, our job cannot be just about saying “no” if the patient is not fit enough for surgery; it must be about giving them the best possible chance of success. When it comes to “promoting healthy lifestyles,” behavioral risks, such as alcohol and tobacco dependence, and low exercise and physical activity, are important targets for public health policy. These too are potentially avoidable risks to perioperative outcomes that we should seek to address. Individual long-term conditions such as diabetes and heart disease, which are targeted in public health endeavors as leading causes of death and disability, also lead to poor outcomes if insufficiently optimized before surgery. The perioperative pathway provides the opportunity for a “teachable moment,” that is, an opportunity to support positive behavioral change. We have a responsibility to capitalize on this—a patient previously reluctant to change behavior might just get the nudge that they need when faced with the risks and potential benefits of surgery. Newer targets for public health policy, which are also of importance in perioperative care, include several composite constructs, such as frailty, multimorbidity, and polypharmacy, particularly in the elderly. These conditions may have been hitherto unrecognized in patients who do not regularly interact with the primary care physicians. Similarly, at the other end of the age spectrum, the perioperative setting offers an opportunity to be vigilant to other risks, such as child abuse, or the health implications of social deprivation such as malnutrition or school absenteeism.
Another fundamental principle of public health practice is to address health inequalities. Perioperative care is no exception to the challenge of differential outcomes—in both elective and emergency surgeries, deprivation is associated with higher mortality and complications, even after adjusting for known clinical risk factors and despite similar standards of care when in hospital. These poor outcomes may be due to worse long-term control of comorbidities, poor health literacy, or poor patient activation however, they undoubtedly have their foundation in the social determinants of health—for example, poor housing, education, and nutrition. Solving these societal challenges may not be within our gift (except through using our democratic right to vote), and we know that such entrenched problems may take decades to resolve. Perhaps then, as anesthesiologists and perioperative physicians, we should be more proactive in developing and evaluating interventions targeted at patients who are high risk because of their socioeconomic status. Important public health advances in recent years include the implementation of screening pathways in patients at high risk of adverse health outcomes based on their family history (for example, ultrasound examination for aortic aneurysms), biological sex (mammography for breast cancer in women), or behavioral habits (CT scanning for lung cancer in smokers). These pathways save lives and improve morbidity through targeting resources to those who most need them and proactively managing health risks when identified. The 20% of our population who live in the most deprived neighborhoods are similarly at risk of worse outcomes, but we generally treat them the same as everyone else when they present for surgery. Development and evaluation of interventions targeted at these individuals should perhaps be a higher priority for us: these might include enhanced preoperative screening and optimization, enhanced perioperative surveillance, and enhanced postoperative follow-up. Such interventions need to be culturally appropriate for the target population to improve the likelihood of compliance and clinical effectiveness—and to achieve this, they must be coproduced with patients and public from these high-risk groups.
As with all public health systems, good perioperative care requires an approach, which is multidisciplinary and multiprofessional and crosses the boundaries of community, primary and secondary care. In the United Kingdom, the COVID-19 pandemic has left our National Health Service (NHS) with a huge backlog of elective surgery to manage, in a population which has deconditioned as a result of lockdowns, and which has generally poorer health due to societal challenges such as the rising cost of living. Therefore, in order to address the backlog and offer better care to our patients, as well as increasing productivity and efficiency of our services, we are focusing on changing how we manage our preoperative pathways. Preoperative assessment clinics and anesthesiologists have long been engaged with detecting potentially modifiable disease and behavioral risk factors, but because most patients are usually seen with only a few weeks to go before an agreed date of surgery, we usually lack the time for optimization. To address this, we are bringing in an additional step to our pathways to screen patients for treatable conditions as early as possible—and ideally before a surgeon makes a decision to operate, or at the very latest, immediately after. Early identification of risk factors, such as poorly controlled diabetes, undiagnosed anemia, frailty, or polypharmacy, will support turning waiting lists into “preparation lists” as previously described. Shared decision-making (SDM) can be embedded early in the perioperative pathway, providing patients with the time and the information required to make a truly informed decision, considering the criteria of Benefits, Risks, Alternative (BRAN) and the do Nothing approach. SDM and the use of decision aids, particularly in higher risk patients, may lead to a higher proportion of patients choosing conservative management options, and, therefore, prevention of the injury associated with “wrong patient surgery.” The teachable moment will become a reality, with behavioral interventions, including weight management, physical exercise, and tobacco cessation programs being offered and the opportunity for patient education taken. Anesthesiologists have long been recognized as potential leaders in this space, but this change in our preoperative pathways will enable this to become a more widely adopted reality. We are embracing the opportunities that digital innovation provides, including the use of app-based patient support tools, implemented in combination with human resources, to provide a safety net for patients who are not digitally enabled. Some may argue that we are not the right people for this job—that the high demand for the unique skills of the anesthesiologist means that we should stay focused on our core business in the OR. However, the role of the anesthesiologist in this context is as the conductor of the orchestra—establishing the protocols and pathways, supporting the wider team of health professionals to identify patients at risk, and overseeing the management of that risk, including intervening in the highest risk patients to enable SDM. Thus, working within a multidisciplinary perioperative care team, the anesthesiologist is delivering on their public health agenda—to improve patient health through promoting healthy lifestyles, treating disease, and preventing injury.
Postpandemic, we have a beleaguered workforce. At the time of writing, in the United Kingdom, nurses are threatening strike action over pay and conditions, for the first time in their union’s history. Junior doctors are being balloted on strike action to argue for increased pay. Senior consultant anesthesiologists are retiring earlier than they might have originally planned, in part because of punitive pension taxation and in larger part due to the psychosocial impact of the pandemic. That impact is affecting health care workers globally and will likely last for years to come, particularly as many nations are now relentlessly focusing on clearing the backlog of surgery which has developed as a result of the pandemic, leaving little or no time for “recovery” of the workforce. However, despite these challenges, the UK anesthesiology community is embracing the public health/perioperative medicine opportunity. This is an opportunity for leadership, requiring the support of our colleagues in primary care, secondary care medicine and our colleagues on the other side of the “blood/brain barrier.” We should not be doing this on our own, any more than the surgeon should attempt the aneurysm repair without our help.
Perhaps most controversially of all—we must consider if the days of the anesthesiologist at the head of every surgical bed may be numbered. While at the moment there is a surge in demand as a result of the growing number of patients having surgery, improvements and wider implementation of closed-loop systems will reduce the need for us to be physically in the room for every patient. At the moment, algorithms are unable to cope with rare events (analogous with the bird strike for the flight deck auto-pilot system). However, a time will come when the algorithms are sufficiently well developed not only to deal with these events as well as humans, but possibly better than humans. I am not particularly a fan of science fiction, but I do recognize the transformational change in all our lives over the course of my 49 years on this planet! These advances must be around the corner—but despite them, humans will continue to have disease, continue to have poor health behaviors, and most sadly of all, we will continue to have disparity in the opportunities and health of the most privileged versus the least. So, the need for us to protect patients and support them to achieve the best surgical outcomes through disease and behavior modification will still be there.
Our work in the OR is not yet done. But the well-known global public health challenge of an increasingly aging population with higher expectations of disease management and health care systems necessitates us taking a step back and considering our wider role in perioperative practice. Our training, skillset, and holistic approach to patient care place us in a great position to take on the public health responsibility for perioperative care. Now, we need to rise to that challenge and work on pathway development and implementation, research priorities, and how we evaluate our efforts.